Group Urges Biden Administration To Install Peers In Top Positions, Reverse Dr. McCance-Katz’s Policies

(12-18-20) A group is urging the incoming Biden administration to appoint individuals with lived mental health experiences to leadership positions in the White House and at SAMHSA and reverse changes that Dr. Elinore McCance-Katz has implemented as the first Assistant Secretary of Mental Health and Substance Abuse.

In a policy paper entitled: Back to Better Behavioral Health prepared for the Biden transition team, the group writes:

“The Biden Administration should look to new leadership at SAMHSA that is uniquely skilled to lead the way in helping our nation to heal by implementing evidence-based policies that advance the principles of recovery, resilience, peer support and trauma informed care. For example, people with lived experience of mental illness and trauma should be placed in high leadership roles to bring back meaning and morale to an agency that evidenced “considerable turnover and declining morale’ “

The group proposes creating a new peer position for Behavioral Health inside the White House and elevating “the voice of persons with lived experience and their families (in) all federal federal agencies.” It also wants to strengthen the IMD Exclusion, increase funding for Protection and Advocacy organizations, and restore funding for the Alternatives Conference.

These recommendations would signal a shift in direction – once again – at SAMHSA. If adopted, some would turn back the clock to how the department used to operate.

Hostility Toward Psychiatric Medicine

Before her appointment, Dr. McCance-Katz criticized SAMHSA’s leadership in a 2016 article, writing:

“There is a perceptible hostility toward psychiatric medicine: a resistance to addressing the treatment needs of those with serious mental illness and a questioning by some at SAMHSA as to whether mental disorders even exist-for example, is psychosis just a “different way of thinking for some experiencing stress?”

Long-time SAMHSA critic, Dr. E. Fuller Torrey, who strongly backed her appointment, noted that SAMHSA’s strategic plan under its former leadership, failed to even mention schizophrenia, which is considered the most serious of all mental illnesses. He argued that SAMHSA promoted feel-good programs aimed at promoting happiness within the general population rather than evidence-based treatments aimed at helping the seriously mentally ill.

Once in office, Dr. McCance-Katz immediately began pushing a different agenda that included promoting greater use of Assisted Outpatient Treatment and a narrowing of what constituted a SAMHSA recognized evidence based practice. A major change was SAMHSA’s push for states to seek waivers of the IMD Exclusion. Her administration said treating those with serious mental illnesses and addictions would be a top priority.

Ron Manderscheid, National Association of County Behavioral Health and Development Disability Directors; Daniel Fisher, National Coalition for Mental Health Recovery; Harvey Rosenthal, New York Association of Psychiatric Rehabilitation Services; Anthony Fox, Tennessee Consumers Mental Health Association; and Helga Luest are behind the Back To Better Behavioral Health recommendations.

IMD Exclusion

One of their most contested recommendations will be for the Biden administration to protect the IMD Exclusion, which has come under considerable attack since its passage in 1965. The exclusion prevents Medicaid payments for care provided in “institutions for mental disease” (IMDs), which are psychiatric hospitals or other residential treatment facilities that have more than 16 beds that mainly provide services to people with mental illnesses.

The National Alliance on Mental Illness, the largest grassroots mental health organization, supports ending the exclusion, calling it discriminatory. The Treatment Advocacy Center also has pushed for an end to the IMD exclusion. In 2018, a bipartisan group led by Senators Dick Durbin (D-IL) and Rob Portman (R-OH), introduced legislation to increase the bed limit in these settings from 16 to up to the first 40 beds in a facility and allow facilities to offer treatment services for up to 60 consecutive days. But all efforts to modify and repeal the exclusion have been blocked by Disability Rights and consumer groups, and lawyers from the Judge David L. Bazelon Center for Mental Health Law.

According to NAMI,

“The IMD exclusion is discriminatory and has had a real-life impact on people’s ability to access needed treatment. Recently, states were given the option to cover short-term stays in psychiatric hospitals under Medicaid by applying for a waiver from the federal government. While this option shows progress, we need to permanently get rid of the IMD exclusion so that every person who relies on Medicaid has access to the full range of treatment options they need – bringing us one step closer towards full and equal treatment under the law.”

But Jennifer Mathis, a Bazelon attorney, offered an opposing view in a 2018 article:

“Although our mental health systems are in crisis, neither the IMD rule nor insufficient hospital beds are the primary problem. The primary problem is the failure to implement an effective system of intensive community-based services, which have been shown to prevent or shorten hospitalizations. Repealing the IMD rule would do little to alleviate the true crises in our public mental health systems and would likely deepen those crises.”

The opioid crisis led to the government granting IMD waivers for states operating addiction facilities with more than 16 beds. That was quickly followed by Dr. McCance-Katz pushing for waivers for mental health services too. Those waivers have enabled states to get around the law and are one of the loopholes that the group contesting them wants to stop. A report in January 2020, noted that states have found numerous other ways to get around the IMD Exclusion rules to pay for services.

Protection and Advocacy

P & A organizations also were heavily criticized during congressional testimony before former Rep. Tim Murphy (R. Pa.) when his Helping Families in Mental Health Crisis Act was being drafted. The P & As drew the wrath of the late advocate D. J. Jaffe, author of Insane Consequences: How The Mental Health Industry Fails the Mentally Ill. Created by Congress in 1986, to protect institutionalized patients from abuse and neglect,  P & As have morphed into Disability Rights groups that have “become the legal arm of those who want to free people with serious mental illnesses from treatment,” Jaffe insisted. Most P & A groups oppose Assisted Outpatient Treatment, which is one reason Jaffe criticized them.

It is unclear how much influence the group pushing its Back To Better Behavioral Health agenda might have with the Biden transition team, given that behemoths such as NAMI, Mental Health America, and the National Council for Behavioral Health, also are offering their own policy suggestions.

But as the appointment of Dr. McCance-Katz has shown, the most important choice that the Biden Administration will make will be choosing a new assistant secretary.

I would urge you to express your opinion to your local NAMI or MHA chapter, as well as your elected members in Congress, about what priorities SAMHSA should have moving forward.

About the author:

Pete Earley is the bestselling author of such books as The Hot House and Crazy. When he is not spending time with his family, he tours the globe advocating for mental health reform.

Learn more about Pete.